PDA Coil Registry Data Submission

Data submission on PDA Coil occlusions is welcomed from all pediatric cardiology programs. Both patient and institution confidentiality is strictly maintained. The Registry currently contains only acute data. Follow-up data will be included in the near future. You are encouraged to submit data regarding all procedures, regardless of outcome.

Data can be submitted using the data entry form (below) either by mail or electronically. The data entry form is also available in a text file that can be printed or used as an E-Mail form. Select the option "Download to disk" in your browser and then click on plain text file. This file contains the data entry form and it can be opened in a word processor and printed . The completed data entry form can be mailed to the address below or sent by electronic mail to cathim@umich.edu or to RBeekman@umich.edu.

Catherine P. Moorehead, M.S.
Pediatric Cardiology
C. S. Mott Children's Hospital
Room F1310, Box 0204
Ann Arbor, MI 48109-0204
FAX (313) 936-9470

Data Entry Form

PDA Coil Registry Data Entry Form

A. DEMOGRAPHICS

Institution:

Operator:

Patient Name:

ID Number:

Weight (kg):

Birth Date (month, day, year):

Procedure Date (month, day, year):

Symptoms (check those that apply):
NONE
CHF
SBE
OTHER
List other symptoms:

Other Pertinent History:
NONE
OTHER Heart Disease
PRIOR Cardiac Intervention
Non Cardiac Condition
List other heart disease, cardiac intervention, or non-cardiac condition:

B. PROCEDURE DATA

Anesthesia (check type used):
SEDATION AND LOCAL
GENERAL

Heparinzation (check yes or no)
YES
NO

Antibiotics (check yes or no)
NO
YES
If yes, Number of Days

Delivery Catheter French Size:
Delivery Catheter Type:
JUDKINS RCA
OTHER
List other type used:

Coil Delivery Route:
TRANSARTERIAL
TRANSVENOUS

Number of Coils Used During Procedure:

Number of Coils Implanted in PDA:

Data on Coils Used
Coil Number 1, CALIBER:
Coil Number 1, DIAMETER:
Coil Number 1, LENGTH:
Coil 1, IMPLANTED?
YES
NO

Coil 1, EMBOLIZED?
NO
Yes to PA
Yes to AO

Coil 1, RETRIEVED?
NO

Coil Number 2, DIAMETER:
Coil Number 2, LENGTH:

Coil 2, IMPLANTED?
YES
NO

Coil 2, EMBOLIZED?
NO
Yes to PA
Yes to AO

Coil 2, RETRIEVED?
NO

Coil Number 3, DIAMETER:
Coil Number 3, LENGTH:

Coil 3, IMPLANTED?
YES
NO

Coil 3, EMBOLIZED?
NO
Yes to PA
Yes to AO

Coil 3, RETRIEVED?
NO

Radiation Time: (minutes)

C. FINDINGS

PDA SIZE (mm):

PDA TYPE (check one):

"A" Conical
"B" Short
"C" Tubular
"D" Complex
"E" Elongated

MURMUR INFORMATION:

PRE COIL
Continuous
Systolic
None or Innocent

POST COIL
Continous
Systolic
None or Innocent

ANGIOGRAPHY DATA:

PRE ANGIO
Large
Moderate
Small
Trace

POST ANGIO
Large
Moderate
Small
Trace
None

PRE COIL PRESSURE DATA:

PA systolic pressure
PA diastolic pressure
PA mean pressure
Ascending Ao systolic pressure
Ascending Ao diastolic pressure
Ascending Ao mean pressure
Ascending to Descending Ao gradient

POST COIL PRESSURE DATA

PA systolic pressure
PA diastolic pressure
PA mean pressure
Ascending Ao systolic pressure
Ascending Ao diastolic pressure
Ascending Ao mean pressure
Ascending to Descending Ao gradient

D. POST PROCEDURE DATA

Post procedure echo (check not done or yes done)
NOT DONE
YES DONE
Indicate number hours post coil:

If echo done indicate results via checkbox below:
NO SHUNT
TRIVIAL SHUNT
SMALL
MODERATE
LARGE

Other post procedure tests (check those that apply):
CXR
ECG
CBC/Hbg/Hct
Holter Monitor
OTHER
list other tests:

Duration of Hospital Stay (chose inpatient or outpatient)

Outpatient
Number of Outpatient Hours

Inpatient
Number of Inpatient Nights

E. COMPLICATIONS: (check all that apply):

NONE
PULSE LOSS
STROKE
TRANSFUSION
HEMATOMA
INFECTION
OTHER
list other complications:

F. COMMENTS:

Your Name:
Submission Date:
Your E-mail Address:

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